Rab
Injection, powder for reconstitution, freeze-dried inactivated Wistar rabies virus strain PM/WI 38 1503-3M cultivated in human diploid cells, net price single-dose vial with syringe containing diluent = £33.90
Excipients include neomycin
Rabipur® (Novartis Vaccines) 
Injection, powder for reconstitution, freeze-dried inactivated Flury LEP rabies virus strain cultivated in chick embryo cells, net price single-dose vial = £28.80
Excipients include neomycin
Rotavirus vaccine
Rotavirus vaccine is a live, oral vaccine that protects young children against gastro-enteritis caused by rotavirus infection. The recommended schedule consists of 2 doses, the first at 2 months of age, and the second at 3 months of age (see Immunisation schedule, section 14.1). The first dose of rotavirus vaccine must be given between 6–15 weeks of age and the second dose should be given after an interval of at least 4 weeks; the vaccine should not be started in children 15 weeks of age or older. Ideally, the full course should be completed before 16 weeks of age to provide protection before the main burden of disease, and to avoid a temporal association between vaccination and intussusception; the course must be completed before 24 weeks of age.
The rotavirus vaccine virus is excreted in the stool and may be transmitted to close contacts; however, vaccination of those with immunosuppressed close contacts may protect the contacts from wild-type rotavirus disease and outweigh any risk from transmission of vaccine virus. Carers of a recently vaccinated baby should be advised of the need to wash their hands after changing the baby’s nappies.
ROTAVIRUS VACCINE
Indications immunisation against gastro-enteritis caused by rotavirus
Cautions see section 14.1; also diarrhoea or vomiting (postpone vaccination); immunosuppressed close contacts (see notes above)
Contra-indications see section 14.1, however, with the exception of severe combined immunodeficiency, benefit from vaccination is likely to outweigh the risk in other types of immunosuppression–if there is any doubt, seek specialist advice; also predisposition to, or history of, intussusception
Side-effects see section 14.1
Dose
By mouth, CHILD over 6 weeks, 2 doses of 1.5 mL, separated by an interval of at least 4 weeks; first dose must be given between 6–15 weeks of age; course should be completed before 24 weeks of age (preferably before 16 weeks)
Rubella vaccine
A combined measles, mumps and rubella vaccine (MMR vaccine) aims to eliminate rubella (German measles) and congenital rubella syndrome. MMR vaccine is used for childhood vaccination as well as for vaccinating adults (including women of child-bearing age) who do not have immunity against rubella (see MMR vaccine)
Single antigen vaccine
No longer available in the UK; the combined live measles, mumps and rubella vaccine is a suitable alternative
Smallpox vaccine
Limited supplies of smallpox vaccine are held at the Specialist and Reference Microbiology Division, Public Health England Colindale (Tel. (020) 8200 4400) for the exclusive use of workers in laboratories where pox viruses (such as vaccinia) are handled.
If a wider use of the vaccine is being considered, Guidelines for smallpox response and management in the post-eradication era should be consulted at www.hpa.org.uk.
Tetanus vaccines
Tetanus vaccine contains a cell-free purified toxin of Clostridium tetani adsorbed on aluminium hydroxide or aluminium phosphate to improve antigenicity.
Primary immunisation for children under 10 years consists of 3 doses of a combined preparation containing adsorbed tetanus vaccine (see Diphtheria-containing Vaccines), with an interval of 1 month between doses. Following routine childhood vaccination, 2 booster doses of a preparation containing adsorbed tetanus vaccine are recommended, the first before school entry and the second before leaving school (see Immunisation schedule, section 14.1).
The recommended schedule of tetanus vaccination not only gives protection against tetanus in childhood but also gives the basic immunity for subsequent booster doses. In most circumstances, a total of 5 doses of tetanus vaccine is considered sufficient for long term protection.
For primary immunisation of adults and children over 10 years previously unimmunised against tetanus, 3 doses of adsorbed diphtheria [low dose], tetanus and poliomyelitis (inactivated) vaccine are given with an interval of 1 month between doses (see Diphtheria-containing Vaccines).
Cautions See also section 14.1. When an individual presents for a booster dose but has been vaccinated following a tetanus-prone wound, the vaccine preparation administered at the time of injury should be determined. If this is not possible, the booster should still be given to ensure adequate protection against all antigens in the booster vaccine.
Very rarely, tetanus has developed after abdominal surgery; patients awaiting elective surgery should be asked about tetanus immunisation and immunised if necessary.
Parenteral drug abuse is also associated with tetanus; those abusing drugs by injection should be vaccinated if unimmunised — booster doses should be given if there is any doubt about their immunisation status.
All laboratory staff should be offered a primary course if unimmunised.
Travel recommendations see section 14.6.
Contra-indications See section 14.1.
Pregnancy See section 14.1.
Breast-feeding See section 14.1.
Side effects See section 14.1.
Wounds Wounds are considered to be tetanus-prone if they are sustained more than 6 hours before surgical treatment or at any interval after injury and are puncture-type (particularly if contaminated with soil or manure) or show much devitalised tissue or are septic or are compound fractures or contain foreign bodies. All wounds should receive thorough cleansing.
For clean wounds: fully immunised individuals (those who have received a total of 5 doses of a tetanus-containing vaccine at appropriate intervals) and those whose primary immunisation is complete (with boosters up to date), do not require tetanus vaccine; individuals whose primary immunisation is incomplete or whose boosters are not up to date require a reinforcing dose of a tetanus-containing vaccine (followed by further doses as required to complete the schedule); non-immunised individuals (or those whose immunisation status is not known or who have been fully immunised but are now immunocompromised) should be given a dose of the appropriate tetanus-containing vaccine immediately (followed by completion of the full course of the vaccine if records confirm the need).
For tetanus-prone wounds: management is as for clean wounds with the addition of a dose of tetanus immunoglobulin (section 14.5.2) given at a different site; in fully immunised individuals and those whose primary immunisation is complete (with boosters up to date) the immunoglobulin is needed only if the risk of infection is especially high (e.g. contamination with manure). Antibacterial prophylaxis (with benzylpenicillin, co-amoxiclav, or metronidazole) may also be required for tetanus-prone wounds.
Tick-borne encephalitis vaccine
Tick-borne encephalitis vaccine contains inactivated tick-borne encephalitis virus cultivated in chick embryo cells. It is recommended for immunisation of those working in, or visiting, high-risk areas (see International Travel, section 14.6). Those working, walking or camping in warm forested areas of Central and Eastern Europe, Scandinavia, Northern and Eastern China, and some parts of Japan, particularly from April to November when ticks are most prevalent, are at greatest risk of tick-borne encephalitis. For full protection, 3 doses of the vaccine are required; booster doses are required every 3–5 years for those still at risk. Ideally, immunisation should be completed at least one month before travel.
TICK-BORNE ENCEPHALITIS VACCINE, INACTIVATED
Indications immunisation against tick-borne encephalitis
Cautions see section 14.1
Contra-indications see section 14.1
Pregnancy see section 14.1
Breast-feeding see section 14.1
Side-effects see section 14.1
Dose
Initial immunisation, by intramuscular injection in deltoid region or anterolateral thigh in infants, ADULT and CHILD over 16 years, 3 doses each of 0.5 mL, second dose after 1–3 months and third dose after further 5–12 months; CHILD 1–16 years 3 doses of 0.25 mL, second dose after 1–3 months and third dose after further 5–12 months; ELDERLY over 60 years and immunocompromised (including those receiving immunosuppressants), antibody concentration may be measured 4 weeks after second dose and dose repeated if protective levels not achieved
Note To achieve more rapid protection, second dose may be given 14 days after first dose
Booster doses, give first dose within 3 years after initial course completed, then every 3–5 years
TicoVac® (MASTA) 
Injection, suspension, formaldehyde-inactivated Neudörfl tick-borne encephalitis virus strain (cultivated in chick embryo cells) adsorbed onto hydrated aluminium hydroxide, net price 0.25-mL prefilled syringe (TicoVac Junior®) = £28.00, 0.5-mL prefilled syringe = £32.00
Excipients include gentamicin and neomycin
Typhoid vaccines
Typhoid vaccine is available as Vi capsular polysaccharide (from Salmonella typhi) vaccine for injection and as live attenuated Salmonella typhi for oral use.
Typhoid immunisation is advised for:
travellers to areas where typhoid is endemic, especially if staying with or visiting local people;
travellers to endemic areas where frequent or prolonged exposure to poor sanitation and poor food hygiene is likely;
laboratory personnel who, in the course of their work, may be exposed to Salmonella typhi.
Typhoid vaccination is not a substitute for scrupulous personal hygiene (see section 14.6).
Capsular polysaccharide typhoid vaccine is usually given by intramuscular injection. Children under 2 years may respond suboptimally to the vaccine, but children aged between 1–2 years should be immunised if the risk of typhoid fever is considered high (immunisation is not recommended for infants under 12 months). Revaccination is needed every 3 years on continued exposure.
Oral typhoid vaccine is a live attenuated vaccine contained in an enteric-coated capsule. One capsule taken on alternate days for a total of 3 doses, provides protection 7–10 days after the last dose. Protection may persist for up to 3 years in those constantly (or repeatedly) exposed to Salmonella typhi, but those who only occasionally travel to endemic areas require further courses at intervals of 1 year.
Interactions Oral typhoid vaccine is inactivated by concomitant administration of antibacterials or antimalarials:
Antibacterials should be avoided for 3 days before and after oral typhoid vaccination;
Mefloquine should be avoided for at least 12 hours before or after oral typhoid;
For other antimalarials vaccination with oral typhoid vaccine should be completed at least 3 days before the first dose of the antimalarial (except proguanil hydrochloride with atovaquone, which may be given concomitantly).
TYPHOID VACCINE
Indications immunisation against typhoid fever
Cautions section 14.1; interactions: see above and Appendix 1 (typhoid vaccine (oral))
Contra-indications section 14.1; also for oral vaccine, acute gastro-intestinal illness
Pregnancy see section 14.1
Breast-feeding see section 14.1
Side-effects section 14.1
Dose
See under preparations
Typhoid polysaccharide vaccine for injection
Typherix® (GSK) 
Injection, Vi capsular polysaccharide typhoid vaccine, 50 micrograms/mL virulence polysaccharide antigen of Salmonella typhi, net price 0.5-mL prefilled syringe = £9.93
Dose by intramuscular injection, 0.5 mL at least 2 weeks before potential exposure to typhoid infection; CHILD under 2 years (see notes above)
Note May be difficult to obtain
Typhim Vi® (Sanofi Pasteur) 
Injection, Vi capsular polysaccharide typhoid vaccine, 50 micrograms/mL virulence polysaccharide antigen of formaldehyde-inactivated Salmonella typhi, net price 0.5-mL prefilled syringe = £9.30
Dose by intramuscular injection, 0.5 mL, at least 2 weeks before potential exposure to typhoid infection CHILD under 2 years (see notes above)
Typhoid vaccine, live (oral)
Vivotif® (Crucell) 
Capsules, e/c, live attenuated Salmonella typhi (Ty21a), net price 3-cap pack = £14.77. Label: 25, counselling, administration
Dose ADULT and CHILD over 6 years, 1 capsule on days 1, 3, and 5
Counselling Take one hour before a meal. Swallow as soon as possible after placing in mouth with a cold or lukewarm drink; it is important to store capsules in a refrigerator
Varicella–zoster vaccines
The live varicella–zoster vaccines, Varilrix® and Varivax®, are licensed for immunisation against varicella (chickenpox) in seronegative individuals. They are not recommended for routine use in children, but can be given to seronegative healthy children over 1 year who come into close contact with individuals at high risk of severe varicella infections. The Department of Health recommends these vaccines for seronegative healthcare workers who come into direct contact with patients. Those with a history of chickenpox or shingles can be considered immune, but healthcare workers with a negative or uncertain history should be tested.
Rarely, the varicella–zoster vaccine virus has been transmitted from the vaccinated individual to close contacts. Therefore, contact with the following should be avoided if a vaccine-related cutaneous rash develops within 4–6 weeks of the first or second dose:
varicella-susceptible pregnant women;
individuals at high risk of severe varicella, including those with immunodeficiency or those receiving immunosuppressive therapy.
Healthcare workers who develop a generalised papular or vesicular rash on vaccination should avoid contact with patients until the lesions have crusted. Those who develop a localised rash after vaccination should cover the lesions and be allowed to continue working unless in contact with patients at high risk of severe varicella.
The high potency, live varicella–zoster vaccine, Zostavax®, is recommended for the prevention of herpes zoster (shingles) in adults who are, or were, 70 years of age on 1 September 2014. The 2014-15 catch-up programme with Zostavax® will be offered to all who are, or were, 78 or 79 years of age on 1 September 2014. A single dose of Zostavax® is likely to give protection for at least 7 years, but the need for, or timing of, a booster dose has not been established. Although Zostavax® is not recommended for the treatment of shingles or post-herpetic neuralgia, it can be given to those with a previous history of shingles; ideally the vaccine should be delayed until systemic antiviral therapy has been completed.
Varicella–zoster immunoglobulin is used to protect susceptible individuals at increased risk of varicella infection.
VARICELLA-ZOSTER VACCINE
Indications see notes above and preparations below
Cautions see section 14.1; also post-vaccination close-contact with susceptible individuals (see notes above)
Contra-indications see section 14.1
Pregnancy avoid pregnancy for 3 months after vaccination; see also section 14.1
Breast-feeding see section 14.1
Side-effects see section 14.1; also conjunctivitis and varicella-like rash; rarely thrombocytopenia
Dose
See under preparations
Varilrix® (GSK) 
Injection, powder for reconstitution, live attenuated varicella–zoster virus (Oka strain) propagated in human diploid cells, net price 0.5-mL vial (with diluent) = £27.31
Excipients include neomycin
Dose prevention of varicella infection (chickenpox), by subcutaneous injection preferably into deltoid region, ADULT and CHILD over 1 year (see notes above), 2 doses of 0.5 mL separated by an interval of at least 6 weeks (minimum 4 weeks)
Varivax® (Sanofi Pasteur) 
Injection powder for reconstitution, live attenuated varicella-zoster virus (Oka/Merck strain) propagated in human diploid cells, net price 0.5-mL vial (with diluent) = £30.28
Excipients include gelatin and neomycin
Dose prevention of varicella infection (chickenpox), by intramuscular or subcutaneous injection into deltoid region (or higher anterolateral thigh in children), ADULT and CHILD over 13 years (see notes above), 2 doses of 0.5 mL separated by 4–8 weeks; CHILD 1–13 years (see notes above) 2 doses of 0.5 mL separated by an interval of at least 4 weeks (two doses separated by 12 weeks in children with asymptomatic HIV infection)
Zostavax® (Sanofi Pasteur) 
Injection, powder for reconstitution, live attenuated varicella–zoster virus (Oka/Merck strain) propagated in human diploid cells, net price single-dose vial (with syringe containing diluent) = £99.96
Excipients include gelatin and neomycin
Dose prevention of herpes zoster (shingles), by subcutaneous injection preferably into deltoid region, ADULT 70–80 years, 0.65 mL as a single dose
Note Advice in BNF may differ from that in product literature
Yellow fever vaccine
Live yellow fever vaccine is indicated for those travelling or living in areas where infection is endemic (see section 14.6) and for laboratory staff who handle the virus or who handle clinical material from suspected cases. Infants under 6 months of age should not be vaccinated because there is a small risk of encephalitis; infants aged 6–9 months should be vaccinated only if the risk of yellow fever is high and unavoidable (seek expert advice). The immunity which probably lasts for life is officially accepted for 10 years starting from 10 days after primary immunisation and for a further 10 years immediately after revaccination.
Very rare, vaccine-associated adverse effects have been reported, such as viscerotropic disease (yellow fever vaccine-associated viscerotropic disease, YEL-AVD), a syndrome which may include metabolic acidosis, muscle and liver cytolysis, and multi-organ failure. Neurological disorders (yellow fever vaccine-associated neurotropic disease, YEL-AND) such as encephalitis have also been reported. These very rare adverse effects usually have occurred after the first dose of yellow fever vaccine in those with no previous immunity.
Pregnancy Live yellow fever vaccine should not be given during pregnancy because there is a theoretical risk of fetal infection. Pregnant women should be advised not to travel to areas at high risk of yellow fever. If exposure cannot be avoided during pregnancy, then the vaccine should be given if the risk from disease in the mother outweighs the risk to the fetus from vaccination.
Breast-feeding Avoid; seek specialist advice if exposure to virus cannot be avoided.
YELLOW FEVER VACCINE, LIVE
Indications immunisation against yellow fever
Cautions see section 14.1; also individuals over 60 years — greater risk of vaccine-associated adverse effects, see notes above
Contra-indications see section 14.1 and notes above; also children under 6 months; history of thymus dysfunction
Pregnancy see notes above
Breast-feeding see notes above
Side-effects see section 14.1; also reported neurotropic disease and viscerotropic disease (see notes above)
Yellow Fever Vaccine, Live 
Yel(live)
Injection, powder for reconstitution, live, attenuated 17D-204 strain of yellow fever virus, cultivated in chick embryos; single dose vial with syringe containing 0.5 mL diluent
Available (only to designated Yellow Fever Vaccination centres) as Stamaril®
14.5 Immunoglobulins
Two types of human immunoglobulin preparation are available, normal immunoglobulin and disease-specific immunoglobulins.
Human immunoglobulin is a sterile preparation of concentrated antibodies (immune globulins) recovered from pooled human plasma or serum obtained from outside the UK, tested and found non-reactive for hepatitis B surface antigen and for antibodies against hepatitis C virus and human immunodeficiency virus (types 1 and 2). A global shortage of human immunoglobulin and the rapidly increasing range of clinical indications for treatment with immunoglobulins has resulted in the need for a Demand Management programme in the UK (for further information consult www.ivig.nhs.uk and Clinical Guidelines for Immunoglobulin Use, www.gov.uk/dh.
Immunoglobulins of animal origin (antisera were frequently associated with hypersensitivity reactions and are no longer used.
Further information on the use of immunoglobulins is included in the Health Protection Agency’s Immunoglobulin Handbook www.hpa.org.uk, and in the Department of Health’s publication, Immunisation against Infectious Disease, www.gov.uk/dh.
Availability Normal immunoglobulin for intramuscular administration is available from some regional Public Health laboratories for protection of contacts and the control of outbreaks of hepatitis A, measles, and rubella only. For other indications, subcutaneous or intravenous normal immunoglobulin should be purchased from the manufacturer.
Disease-specific immunoglobulins (section 14.5.2) are available from some regional Public Health laboratories, with the exception of tetanus immunoglobulin which is available from BPL, hospital pharmacies, or blood transfusion departments. Rabies immunoglobulin is available from the Specialist and Reference Microbiology Division, Public Health England, Colindale. Hepatitis B immunoglobulin required by transplant centres should be obtained commercially.
In Scotland all immunoglobulins are available from the Scottish National Blood Transfusion Service (SNBTS).
In Wales all immunoglobulins are available from the Welsh Blood Service (WBS).
In Northern Ireland all immunoglobulins are available from the Northern Ireland Blood Transfusion Service (NIBTS).
14.5.1 Normal immunoglobulin
Human normal immunoglobulin (‘HNIG’) is prepared from pools of at least 1000 donations of human plasma; it contains immunoglobulin G (IgG) and antibodies to hepatitis A, measles, mumps, rubella, varicella, and other viruses that are currently prevalent in the general population.
Normal immunoglobulin may interfere with the immune response to live virus vaccines which should therefore only be given at least 3 weeks before or 3 months after an injection of normal immunoglobulin (this does not apply to yellow fever vaccine since normal immunoglobulin does not contain antibody to this virus).
Uses Normal immunoglobulin (containing 10%–18% protein) is administered by intramuscular injection for the protection of susceptible contacts against hepatitis A virus (infectious hepatitis), measles and, to a lesser extent, rubella. Injection of immunoglobulin produces immediate protection lasting several weeks.
Normal immunoglobulin (containing 3%–12% protein) for intravenous administration is used as replacement therapy for patients with congenital agammaglobulinaemia and hypogammaglobulinaemia, and for the short-term treatment of idiopathic thrombocytopenic purpura and Kawasaki disease; it is also used for the prophylaxis of infection following bone-marrow transplantation and in children with symptomatic HIV infection who have recurrent bacterial infections. Normal immunoglobulin for replacement therapy may also be given intramuscularly or subcutaneously, but intravenous formulations are normally preferred. Intravenous immunoglobulin is also used in the treatment of Guillain-Barré syndrome as an alternative to plasma exchange.
For guidance on the use of intravenous normal immunoglobulins and alternative therapies for certain conditions, consult Clinical Guidelines for Immunoglobulin Use (www.gov.uk/dh).
Hepatitis A Hepatitis A vaccine is preferred for individuals at risk of infection (see Hepatitis A vaccine) including those visiting areas where the disease is highly endemic (all countries excluding Northern and Western Europe, North America, Japan, Australia, and New Zealand). In unimmunised individuals, transmission of hepatitis A is reduced by good hygiene. Intramuscular normal immunoglobulin is no longer recommended for routine prophylaxis in travellers, but it may be indicated for immunocompromised patients if their antibody response to the vaccine is unlikely to be adequate.
Intramuscular normal immunoglobulin is recommended for prevention of infection in close contacts (of confirmed cases of hepatitis A) who have chronic liver disease or HIV infection, or who are immunosuppressed or over 50 years of age; normal immunoglobulin should be given as soon as possible, preferably within 14 days of exposure to the primary case. However, normal immunoglobulin can still be given to contacts at risk of severe disease up to 28 days after exposure to the primary case. Hepatitis A vaccine can be given at the same time, but it should be given at a separate injection site.
Measles Intravenous or subcutaneous normal immunoglobulin may be given to prevent or attenuate an attack of measles in individuals who do not have adequate immunity. Children and adults with compromised immunity who have come into contact with measles should receive intravenous or subcutaneous normal immunoglobulin as soon as possible after exposure. It is most effective if given within 72 hours but can be effective if given within 6 days.
Subcutaneous or intramuscular normal immunoglobulin should also be considered for the following individuals if they have been in contact with a confirmed case of measles or with a person associated with a local outbreak:
non-immune pregnant women;
infants under 9 months.
Further advice should be sought from the Centre for Infections, Public Health England (tel. (020) 8200 6868).
Individuals with normal immunity who are not in the above categories and who have not been fully immunised against measles, can be given MMR vaccine (section 14.4) for prophylaxis following exposure to measles.
Rubella Intramuscular immunoglobulin after exposure to rubella does not prevent infection in non-immune contacts and is not recommended for protection of pregnant women exposed to rubella. It may, however, reduce the likelihood of a clinical attack which may possibly reduce the risk to the fetus. Risk of intrauterine transmission is greatest in the first 11 weeks of pregnancy, between 16 and 20 weeks there is minimal risk of deafness only, after 20 weeks there is no increased risk. Intramuscular normal immunoglobulin should be used only if termination of pregnancy would be unacceptable to the pregnant woman — it should be given as soon as possible after exposure. Serological follow-up of recipients is essential to determine if the woman has become infected despite receiving immunoglobulin.
For routine prophylaxis against Rubella, see MMR vaccine.
NORMAL IMMUNOGLOBULIN
Indications see notes above
Cautions hypo- or agammaglobulinaemia with or without IgA deficiency; interference with live virus vaccines — see notes above
Intravenous use thrombophilic disorders, or risk factors for arterial or venous thromboembolic events; obesity; ensure adequate hydration, renal insufficiency
Contra-indications patients with selective IgA deficiency who have known antibody against IgA
Renal impairment monitor for acute renal failure; consider discontinuation if renal function deteriorates. Intravenous preparations with added sucrose have been associated with cases of renal dysfunction and acute renal failure
Side-effects nausea, diarrhoea, chills, fever, headache, dizziness, arthralgia, myalgia, muscle spasms, low back pain; rarely hypotension, anaphylaxis, cutaneous skin reactions, aseptic meningitis, acute renal failure; also reported with intravenous use, injection site reactions, abdominal pain and distension, blood pressure fluctuations, haemolytic anaemia, thromboembolic events including myocardial infarction, stroke, pulmonary embolism, and deep vein thrombosis
Note Adverse reactions are more likely to occur in patients receiving normal immunoglobulin for the first time, or following a prolonged period between treatments, or when a different brand of normal immunoglobulin is administered.
Dose
See under preparations
Note Antibody titres can vary widely between normal immunoglobulin preparations from different manufacturers — formulations are not interchangeable; patients should be maintained on the same formulation throughout long-term treatment to avoid adverse effects
For intramuscular use
Normal Immunoglobulin 
Normal immunoglobulin injection. 250-mg vial; 750-mg vial
Dose by deep intramuscular injection, to control outbreaks of hepatitis A (see notes above), 500 mg; CHILD under 10 years 250 mg
Rubella in pregnancy, prevention of clinical attack, 750 mg
Available from the Centre for Infections and other regional Health Protection Agency offices (for contacts and control of outbreaks only, see section 14.5 under Availability)
For subcutaneous use
Gammanorm® (Octapharma) 
Normal immunoglobulin (protein 16.5%) injection, net price 1.65 g (10 mL) = £96.77, 3.3 g (20 mL) = £193.55
Electrolytes Na+ 1.09 mmol/10-mL vial
Dose by subcutaneous infusion, antibody deficiency syndromes, consult product literature
Note May be administered by intramuscular injection (if subcutaneous route not possible) but not for patients with thrombocytopenia or other bleeding disorders
Hizentra® (CSL Behring) 
Normal immunoglobulin (protein 20%) injection, net price 1 g (5 mL) = £45.90, 2 g (10 mL) = £91.80, 4 g (20 mL) = £183.60
Note Contains L-proline; contra-indicated in patients with hyperprolinaemia
Dose by subcutaneous infusion, antibody deficiency syndromes, consult product literature
Subcuvia® (Baxter) 
Normal immunoglobulin (protein 16%) injection, net price 800 mg (5 mL) = £32.56, 1.6 g (10 mL) = £65.12
Dose by subcutaneous infusion, ADULT and CHILD over 12 years antibody deficiency syndromes, consult product literature
Note May be administered by intramuscular injection (if subcutaneous route not possible) but not for patients with thrombocytopenia or other bleeding disorders
Subgam® (BPL) 
Normal immunoglobulin (protein 14%-18%) injection, net price 250-mg vial = £11.20, 750-mg vial = £34.20, 1.5-g vial = £68.40
Dose by subcutaneous infusion, antibody deficiency syndromes, consult product literature
By intramuscular injection, Hepatitis A prophylaxis in outbreaks (see notes above), ADULT and CHILD over 10 years, 750 mg, CHILD under 10 years, 500 mg
Rubella, in pregnancy, prevention of clinical attack (see also notes above), 750 mg
Note Subgam® is not licensed for prophylactic use, but due to difficulty in obtaining suitable immunoglobulin products, the Health Protection Agency recommends intramuscular use for prophylaxis against Hepatitis A or rubella
For intravenous use
Note Dose recommendation for Kawasaki disease, see BNF for Children; other indications — consult product literature for dosage regimens
Aragam® (Oxbridge) 
Intravenous infusion, human normal immunoglobulin, protein 5%, net price 2.5 g (50 mL) = £145.00, 5 g (100 mL) = £290.00, 10 g (200 mL) = £580.00, 20 g (400 mL) = £1160.00
Excipients include glucose 50 mg/mL
Flebogamma® DIF (Grifols) 
Intravenous infusion, human normal immunoglobulin, protein 5%, net price 0.5 g (10 mL) = £30.00, 2.5 g (50 mL) = £127.50, 5 g (100 mL) = £255.00, 10 g (200 mL) = £510.00, 20 g (400 mL) = £1020.00; protein 10%, 5 g (50 mL) = £300.00, 10 g (100 mL) = £600.00, 20 g (200 mL) = £1200.00
Note Both strengths contain sorbitol 50 mg/mL; contra-indicated in patients with hereditary fructose intolerance
Gammagard S/D® (Baxter) 
Intravenous infusion, (providing protein 5% or 10%), net price 5 g (with diluent) = £200.50, 10 g (with diluent) = £401.00
Gammaplex® (BPL) 
Intravenous infusion, human normal immunoglobulin (protein 5%), net price 2.5 g (50 mL) = £104.50, 5 g (100 mL) = £209.00, 10 g (200 mL) = £418.00
Note Contains sorbitol 50 mg/mL; contra-indicated in patients with hereditary fructose intolerance
Gamunex® (Grifols) 
Intravenous infusion, human normal immunoglobulin (protein 10%), net price 5 g (50 mL) = £212.50, 10 g (100 mL) = £425.00, 20 g (200 mL) = £850.00
Note Use Glucose 5% intravenous infusion if dilution prior to infusion is required
Intratect® (Biotest UK) 
Intravenous infusion, human normal immunoglobulin, protein 5%, net price 1 g (20 mL) = £45.00, 2.5 g (50 mL) = £112.50, 5 g (100 mL) = £225.00, 10 g (200 mL) = £450.00; protein 10%, 1 g (10 mL) = £45.00, 5 g (50 mL) = £225.00, 10 g (100 mL) = £450.00, 20 g (200 mL) = £900.00
Kiovig® (Baxter) 
Intravenous infusion, human normal immunoglobulin (protein 10%), net price 1 g (10 mL) = £49.00, 2.5 g (25 mL) = £122.50, 5 g (50 mL) = £245.00, 10 g (100 mL) = £490.00, 20 g (200 mL) = £980.00, 30 g (300 mL) = £1470.00
Note Use Glucose 5% intravenous infusion, if dilution prior to administration is required
Octagam® (Octapharma) 
Intravenous infusion, human normal immunoglobulin, protein 5%, net price 2.5 g (50 mL) = £102.00, 5 g (100 mL) = £204.00, 10 g (200 mL) = £408.00; protein 10%, 2 g (20 mL) = £117.30, 5 g (50 mL) = £293.25, 10 g (100 mL) = £586.50, 20 g (200 mL) = £1173.00
Note Contains maltose (may cause falsely elevated results with blood glucose testing systems)
Privigen® (CSL Behring) 
Intravenous infusion, human normal immunoglobulin (protein 10%), net price 2.5 g (25 mL) = £114.75, 5 g (50 mL) = £229.50, 10 g (100 mL) = £459.00, 20 g (200 mL) = £918.00
Note Contains L-proline; contra-indicated in patients with hyperprolinaemia
Vigam® (BPL) 
Intravenous infusion, human normal immunoglobulin (protein 5%), net price 2.5 g (50 mL) = £95.00, 5 g (100 mL) = £209.00, 10 g (200 mL) = £418.00
Note Contains sucrose (see Renal impairment, above)
14.5.2 Disease-specific immunoglobulins
Specific immunoglobulins are prepared by pooling the plasma of selected human donors with high levels of the specific antibody required. For further information, see Immunoglobulin Handbook (www.hpa.org.uk).
There are no specific immunoglobulins for hepatitis A, measles, or rubella — normal immunoglobulin, section 14.5.1 is used in certain circumstances. There is no specific immunoglobulin for mumps; neither normal immunoglobulin nor MMR vaccine is effective as post-exposure prophylaxis.
Hepatitis B
Disease-specific hepatitis B immunoglobulin (‘HBIG’) is available for use in association with hepatitis B vaccine for the prevention of infection in laboratory and other personnel who have been accidentally inoculated with hepatitis B virus, and in infants born to mothers who have become infected with this virus in pregnancy or who are high-risk carriers (see Hepatitis B Vaccine, section 14.4). Hepatitis B immunoglobulin will not inhibit the antibody response when given at the same time as hepatitis B vaccine but should be given at different sites.
An intravenous and subcutaneous preparation of hepatitis B-specific immunoglobulin is licensed for the prevention of hepatitis B recurrence in HBV-DNA negative patients who have undergone liver transplantation for liver failure caused by the virus.
HEPATITIS B IMMUNOGLOBULIN
Indications prophylaxis against hepatitis B infection
Cautions IgA deficiency; interference with live virus vaccines see under Normal Immunoglobulin.
Side-effects injection site reactions; less frequently, buccal ulceration, glossitis, abdominal pain, chest pain, dyspnoea, anaphylaxis, tremor, dizziness, headache, arthralgia; for side-effects associated with intravenous immunoglobulin, see section 14.5.1
For intramuscular use
Hepatitis B Immunoglobulin 
Injection, hepatitis B-specific immunoglobulin, 100 units/mL. Vials containing 200 units or 500 units, available from selected Health Protection Agency and NHS laboratories (except for Transplant Centres, see section 14.5 under Availability), also available from BPL
Dose by intramuscular injection (as soon as possible after exposure; ideally within 12–48 hours, but no later than 7 days after exposure), ADULT and CHILD over 10 years 500 units; CHILD under 5 years 200 units, 5–9 years 300 units; NEONATE 200 units
Prevention of transmitted infection at birth, NEONATE 200 units as soon as possible after birth; for full details consult Immunisation against Infectious Disease (www.dh.gov.uk)
For intravenous use
Hepatect®CP (Biotest UK) 
Intravenous infusion, hepatitis B-specific immunoglobulin 50 units/mL, net price 500 units (10 mL) = £300.00, 2000 units (40 mL) = £1100.00, 5000 units (100 mL) = £3000.00
Dose by intravenous infusion, after exposure to hepatitis B virus-contaminated material — consult product literature
Prevention of transmitted infection at birth — consult product literature
Prevention of hepatitis B in haemodialysed patients, prophylaxis against re-infection of transplanted liver — consult product literature
For subcutaneous use
Zutectra® (Biotest UK) 
Injection, hepatitis B-specific immunoglobulin, 500 units/mL, net price 5 × 1-mL prefilled syringes = £1500.00
Dose prevention of hepatitis B re-infection more than 6 months after liver transplantation in stable HBV-DNA negative patients starting 2–3 weeks after last dose of intravenous hepatitis B immunoglobulin, by subcutaneous injection, ADULT body-weight under 75 kg 500 units once weekly, increased if necessary up to 1000 units once weekly; body-weight over 75 kg 1000 units once weekly
Rabies
Following exposure of an unimmunised individual to an animal in or from a country where the risk of rabies is high the site of the bite should be washed with soapy water and specific rabies immunoglobulin of human origin administered. All of the dose should be injected around the site of the wound; if this is difficult or the wound has completely healed it can be given in the anterolateral thigh (remote from the site used for vaccination).
Rabies vaccine should also be given intramuscularly at a different site (for details see Rabies vaccine). If there is delay in giving the rabies immunoglobulin, it should be given within 7 days of starting the course of rabies vaccine.
RABIES IMMUNOGLOBULIN
Indications post-exposure prophylaxis against rabies infection
Cautions IgA deficiency; interference with live virus vaccines — see under Normal Immunoglobulin
Side-effects injection site swelling and pain; very rarely anaphylaxis; buccal ulceration, glossitis, chest tightness, dyspnoea, tremor, dizziness, arthralgia, and facial oedema also reported
Dose
See under preparation
Rabies Immunoglobulin 
(Antirabies Immunoglobulin Injection)
See notes above
Dose 20 units/kg by infiltration in and around the cleansed wound; if wound not visible or healed or if infiltration of whole volume not possible, give remainder by intramuscular injection into anterolateral thigh (remote from vaccination site)
Note The potency of individual batches of rabies immunoglobulin from the manufacturer may vary; potency may also be described differently by different manufacturers. It is therefore critical to know the potency of the batch to be used and the weight of the patient in order to calculate the specific volume required to provide the necessary dose
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